A Solo Doc's attempt to make sense of the business of medicine while he grows (from its infancy) a primary care practice in the island of Manhattan.

Monday, November 20, 2006

Doctor beware...... your reimbursements rates may have been subversively dropped!

As if yearly reimbursement rate cuts were not enough, it seems that Aetna throws in a curve ball every so often just to see if I'm still awake. Last week, I received the EOB (Explanation of Benefits for those of you that may not know that dilineates how claims are paid) for some recent claims and immediately noticed a greater than 40% drop (aah!) in payments for given CPT codes. What? I couldn't believe it, but then again, they've done it before in different ways. See, I'm fee-for-service with Aetna, and the rates have been negotiated by an IPA (Internal Practice Associates) that I belong to, so Aetna can't go changing my rates arbitrarily. This protects me as a solo practitioner dealing with the big-wigs. However, it seems that Aetna tries to sneakily lower its payments when you're not looking. I've spoken to other physicians in my neighborhood and they've experienced similar behavior. In fact, one of them didn't even notice Aetna had lowered his reimbursements way below the negotiated IPA fees until it was too late. He lost 6 months worth of payments he could not argue for or retrieve. You see, he did not notice the infraction until a year after they had started, and they only allow you to request claim corrections for the 6 months prior. Interestingly, on the other hand, if an insurance company realizes that they overpayed you for a claim that is greater than 1 year old, there's nothing to stop them from putting that overpayment to collections from you or sending you threatening letters that if you don't return the overpayment, they will subtract it from your next payment. It's simple as that: Goliath against David.

Another trick Aetna has used is switching me from fee-for-service (which is how I have elected to be payed) to capitated, then paying me $2 for a visit. The story is always the same -- "Oh, we don't know how this happened...(with a batting of the innocent eyelashes)." Yeah, right! You're in the business of making money, not paying claims.

So doctor beware. Don't expect your biller to catch this. Here are some helpful hints:1) Know what your reimbursement rates are for each insurer for every CPT code you use.2) Even if you have a biller, review your EOBs periodically. Check that you are being paid the contractual amount. It's better to take the extra time than to find out too late you've been underpaid by $6,000.3) If you discover an underpayment, call the Insurance plan immediately or if you are a member of an IPA, call them to help you with this matter. Have the EOBs at hand. The insurance plan needs to know you're on top of this.4) Consider filing a complaint with your local medical society.

They didn't teach you this in medical school, but you have to be a shark to swim with the killer whales.

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About Me

sha-man n. A member of certain tribal societies who acts as a medium between the visible world and an invisible spirit world and who practices magic or sorcery for purposes of healing, divination, and control over natural events.